SSA-L2765, Request for Self-Employment Information, SSA-L3365, Request for Employee Information, SSA-L4002, Request for Employer Information

Forms and Documents

Document Name	Status
Form SSA-L2765 SSA-L2765, Request for Self-Employment Information Form	Modified
Form SSA-L4002 SSA-L4002, Request for Employer Information Form	Modified
Form SSA-L3365 SSA-L3365, Request for Employee Information Form	Modified
0508 Addendum.doc Supplementary Document	2017-01-17
Supporting Statement - 0508.docx Supporting Statement A	2017-01-23

IC Document Collections

IC ID	Document Title	Status
9413	SSA-L2765, Request for Self-Employment Information Form	Modified
178763	SSA-L4002, Request for Employer Information Form	Modified
178761	SSA-L3365, Request for Employee Information Form	Modified

ICR Details

OMB Control No: 0960-0508	ICR Reference No: 201610-0960-002
Status: Active	Previous ICR Reference No: 201309-0960-005
Agency/Subagency: SSA	Agency Tracking No:
Title: SSA-L2765, Request for Self-Employment Information, SSA-L3365, Request for Employee Information, SSA-L4002, Request for Employer Information
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/07/2017
	Date Received in OIRA: 01/23/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2020	36 Months From Approved	07/31/2017
Responses	313,749	0	313,749
Time Burden (Hours)	52,292	0	52,292
Cost Burden (Dollars)	0	0	0

---

Abstract: A small percentage of an individual's earnings are reported to SSA without a social security number (SSN) or with an incorrect name or SSN. SSA must write to the individual or to the employer asking for correction of the missing or incorrect information. These forms have been designed by SSA to meet this requirement. The respondents are self-employed individuals, employees, or an employee's employer, in situations where SSA is unable to identify the individual based on the information submitted.

---

Authorizing Statute(s): US Code: 42 USC 405 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 73189	10/24/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 3838	01/12/2017
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
SSA-L2765, Request for Self-Employment Information	SSA-L2765	Request for Self-Employment Information
SSA-L3365, Request for Employee Information	SSA-L3365	Request for Employee Information
SSA-L4002, Request for Employer Information	SSA-L4002	Request for Employer Information

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	313,749	313,749	0	0	0	0
Annual Time Burden (Hours)	52,292	52,292	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $3,724,824

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 01/23/2017

---